Medical Release Form - Life Action Camp
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Medical Release Form
1. Health Care Permission
I,
, the parent/legal guardian of the child named below, hereby make the
Life Action Camp staff the true and lawful attorney-in-fact for my child in my name and stead. I hereby give permission
to the medical personnel selected by the Life Action Camp staff to provide routine health care; to administer medica-
tions; to order X-rays, routine tests, treatment; to release any records necessary for insurance purposes; and to provide
or arrange necessary related transportation for my child. In the event that I cannot be reached in an emergency, I
hereby give permission to the physician selected by the Life Action Camp staff to secure and administer treatment,
including hospitalization, for the person named below.
Full Name of Child
Parent/Legal Guardian’s Signature
Date
2. In case of emergency, please call:
Home: ( ______ ) ______-___________
Name: ____________,
cell: ( ______ ) ______-___________,
work: ( ______ ) ______-___________
Name: ____________,
cell: ( ______ ) ______-___________,
work: ( ______ ) ______-___________
3. Medications:
In the case of over-the-counter treatments, my child is allergic to or I would prefer that my child did not have
the following:
1.
3.
2.
4.
Furthermore, because of health needs, my child routinely takes the following medications:
1.
3.
2.
4.
4. Insurance Information:
Please make a copy of both sides of your medical insurance or health care card and
send that along with this form.
Life Action takes your personal medical information very seriously. We will not disclose your information to anyone unless deemed necessary for
medical treatment. In that case, it will only be disclosed to those involved in providing medical treatment or general health care.
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